What is the initial dose of Novorapid (aspart insulin) for a non-diabetic individual on corticosteroids with hyperglycemia?

Management of Hyperglycemia in a Non-Diabetic Patient on Corticosteroids

For a non-diabetic patient on corticosteroids with a blood glucose level of 19.5 mmol/L, the initial dose of NovoRapid (insulin aspart) should be calculated at 0.1-0.2 units/kg body weight, with approximately 4-6 units administered immediately to address the acute hyperglycemia. 1

Initial Assessment and Management

• Blood glucose of 19.5 mmol/L (351 mg/dL) in a non-diabetic patient on corticosteroids represents steroid-induced hyperglycemia requiring prompt intervention
• This level of hyperglycemia significantly increases risk of complications including:
  • Dehydration
  • Electrolyte abnormalities
  • Increased risk of infection
  • Potential progression to hyperosmolar hyperglycemic state

Immediate Insulin Management

1. Initial correction dose:

   • Administer 4-6 units of NovoRapid immediately
   • Recheck blood glucose in 2 hours

2. Ongoing insulin regimen:

   • Calculate total daily insulin requirement at 0.3-0.5 units/kg/day 1
   • Divide this total between:
     • Basal insulin (long-acting): 50% of total daily dose
     • Bolus insulin (NovoRapid): 50% of total daily dose, split between meals

Specific Dosing Considerations

• For a 70kg patient, this would translate to:

  • Total daily dose: 21-35 units (0.3-0.5 units/kg)
  • Basal component: 10-17 units once daily
  • Bolus (NovoRapid): 10-17 units divided between meals (approximately 3-6 units per meal)

• For higher blood glucose readings, use this correction scale with NovoRapid:

  • BG 14-16 mmol/L: Add 2 units
  • BG 16-19 mmol/L: Add 4 units
  • BG >19 mmol/L: Add 6 units 2

Monitoring Protocol

• Check blood glucose before meals and at bedtime
• Target blood glucose range: 5-10 mmol/L 1
• Monitor for 48 hours after initiating corticosteroids, as 94% of patients who develop hyperglycemia will do so within this timeframe 3
• Adjust insulin doses every 1-2 days based on glucose patterns

Important Considerations

• Steroid-induced hyperglycemia typically peaks 7-9 hours after steroid administration 1
• For once-daily morning corticosteroid dosing, hyperglycemia typically peaks in the afternoon and may normalize by the next morning 3
• Insulin requirements correlate directly with steroid dose - higher steroid doses require higher insulin doses 1, 4
• Avoid relying solely on correction or "sliding scale" insulin without adequate basal insulin coverage 2

Cautions and Pitfalls

• Risk of hypoglycemia increases with:

  • Irregular eating patterns
  • Renal impairment
  • Elderly patients

• When corticosteroid doses are reduced, insulin requirements will decrease rapidly - doses must be proactively adjusted to prevent hypoglycemia 1

• Sulfonylureas are not recommended for management of steroid-induced hyperglycemia 1

• For very severe hyperglycemia (>20 mmol/L) that persists despite treatment, hospital admission may be warranted 1

Patient Education

• Educate on glucose monitoring, symptoms of hyperglycemia and hypoglycemia
• Emphasize that insulin requirements will change as steroid doses change
• Ensure patient has access to rapid-acting carbohydrates for hypoglycemia management

By following this structured approach, steroid-induced hyperglycemia can be effectively managed while minimizing the risk of complications.